Sunday, August 12, 2012

Consult

The patient was in the ICU, actively psychotic and with a dangerously low hematocrit and advanced HIV disease.

He was refusing a life-saving transfusion.

As ever, the consult to the psychiatry team was made in response to the patient’s refusal to comply with the primary team’s medical advice. Our call was to evaluate for him for medical decision-making capacity.

The assumption was that, in this elderly, schizophrenic patient with active delusions about his personal powers and his relationship with God, there was clearly no way that he fully understood his condition or his medical treatment or the ramifications of not accepting that treatment.

It seemed, at first glance, to be a rather cut-and-dried case. After meeting with him, our team decided that he did not have decision-making capacity since his rationale for refusal of blood products was based on his delusions. From a consult perspective, it was open-and-closed. Textbook definition of not having capacity.

But something about the case just did not sit right.

He was an old man. He was certainly psychotic, but had no history of threatening himself or others. He looked sick – his significant medical problems had left him emaciated and weak. He had been arrested for public urination – he was homeless. And the only thing he wanted was to be left alone. The police had brought him to the hospital when they realized that he was muttering to himself and saying some pretty strange things.

But even though he clearly had delusional beliefs, he was adamant – and consistent – about not wanting blood products or other medications. And this was not the first time he had found himself in this exact same situation. Being hauled into the hospital by the police, being found without capacity to make decisions about his own medical care, being forcibly restrained, having IV lines inserted, treated with medications and blood transfusions, and then being discharged again back out to the same situation he came from. Only to have the scene repeat itself a few weeks later. And everything about the process from beginning to end remained the same, including the fact that he was still psychotic, muttering to himself, living on the street, getting sicker and weaker, wanting to be left to his own devices and to commune with his God in his own way, and still insisting that he did not want our medical treatment, no matter what we said it would do for him.

He looked at us with such despair from his position on the bed, after all four of his limbs had been tightly strapped down to it, that it made my heart hurt.

He would not live long without medical treatment. But, to him, being forced to accept that treatment was the worst thing in the world. Technically, legally, he met criteria for not being able to make his own medical decisions, and his doctors were within their rights to give him this life-saving treatment, even against his will. But he didn’t want it. He didn’t believe it was right to get someone else’s blood. And watching him being forced to accept it made me wonder whether our “textbook definitions” really do encompass the best possible compassionate care for our patients. Patients who, homeless or not, elderly or not, psychotic or not, are human beings deserving of the most humane treatments we can offer – even if that treatment might sometimes be none at all.